Background
Assisted living technologies
The myth of the smart home
‘Lift the cover, peer behind the panels, or look underneath the floor, and you will find a maze of cables, connectors, and infrastructural components…. Push further, and you will encounter regulatory authorities who authorize interventions and certify qualified individuals, committees that resolve conflicting demands in the process of setting standards, governments that set policy, bureaucrats who implement it, marketers who shape our views of the role of the infrastructure in our lives, and more. Mess is always nearby’ (page 4) [11].
The uniqueness of assisted living needs
Methods
The ATHENE study
Sample and setting
Age (median, range) 81 (60 to 98) years
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Number
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Gender | |
Male | 13 |
Female | 27 |
Ethnicity | |
White British | 24 |
Other European | 1 |
South Asian | 4 |
Chinese | 3 |
Caribbean | 5 |
African | 2 |
Housing status | |
Own house or flat | 19 |
Privately rented | 1 |
Housing association | 7 |
Local authority | 10 |
Sheltered housing (that is, with resident warden) | 3 |
Living arrangements | |
Alone | 18 |
With partner only | 13 |
With partner and/or other carer | 9 |
Objective medical conditions
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Number
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---|---|
Neurological conditions (stroke, Parkinson’s, other tremor, severe migraine, past polio, not formally diagnosed) | 20 |
Arthritis | 14 |
High blood pressure and/or high cholesterol | 14 |
Chronic respiratory disease (asthma, chronic obstructive pulmonary disease) | 13 |
Diabetes | 11 |
Macular degeneration, glaucoma or cataract | 11 |
Coronary heart disease | 10 |
Depression, anxiety or psychological stress | 7 |
Dementia, cognitive or memory problems | 7 |
Side effects from medication | 7 |
Trauma (for example, recent or persisting effect of past fracture) | 6 |
Swollen feet without formal diagnosis | 3 |
Cancer | 2 |
Other (e.g. urogenital, kidney failure, anaemia, tendency to infections, hormone deficiency, peptic ulcer, sleep apnoea, deafness) | 16 |
Subjective impairments affecting basic day to day tasks
| |
Generalised tiredness/low energy | 23 |
Significant and persistent pain | 18 |
Stiffness or weakness in joints and/or muscles | 18 |
Shortness of breath | 13 |
Poor or no vision | 11 |
Unsteadiness, dizziness or balance problems | 9 |
Poor cognitive capacity, concentration or confidence | 11 |
One or more limbs paralysed | 7 |
Bulky device affecting mobility (e.g. oxygen cylinder, catheter) | 7 |
Incontinence | 6 |
Difficulty with fine finger movements and/or writing | 5 |
Blackouts, loss of consciousness or perceived risk of these | 5 |
Physical bulk (obesity, severely swollen legs) | 4 |
Wandering | 2 |
Theoretical position
Phase 1: Interviews
Phase 2: Ethnographic studies
Phase 3: Co-design workshops
Data analysis
Results
Stakeholder interviews
Ethnographic case studies
Walter, a white British man aged 72, is single and lives with Christine [friend] along with her partner Phil, and their four children. […] He has chronic obstructive pulmonary disease (COPD) as a result, he thinks, of his lifelong smoking. He says he used to have home oxygen last year for the COPD but the nurse told him he didn’t need it because his oxygen levels were OK. Walter disagrees with the nurse’s assessment. He said he feels he needs oxygen sometimes. He has high blood pressure, and also prostate problems that have led to urinary incontinence, for which he wears pads. Walter says he can go [to the pub] for a couple of pints, go to the toilet, and then still find himself ‘leaking’. Because of his urinary problems and his breathing, Walter’s sleep is very disturbed.While Walter says, ‘I don’t have any problems, memory wise’, Christine explains that he does have memory problems (for example, he naps for an hour then wakes up and thinks it is the next morning), and he also has vacant periods for reasons that are unclear. He is waiting for an appointment for a brain scan. At night, Walter sometimes wanders about the house and tries to cook. This is not safe (he has burned toast in the past), so Christine has put a lock on the kitchen door.Walter spends most of his time indoors watching TV, going outside periodically for a cigarette. The house is small and very cluttered with a tiny outside yard, and with 7 people and numerous animals, there is not much spare space. The nurses have talked about Walter having a wheelchair but Christine is not keen. There is no room in the cramped house to store it. Walter does not feel he needs a wheelchair. What they would really like is for the council to put a large gate on the back garden fence so they can get the car in, making it easier to get Walter into the car, especially on cold and rainy days.Walter is on various medications, tablets and inhalers for the COPD and more tablets for the prostate problem. He has regular visits from health professionals and is somewhat confused about these. He has had telehealth equipment installed for about a year but he does not use it now and nobody has been to collect it […]. The devices include an oximeter, blood pressure monitor, thermometer and weighing scales. He still has a nebuliser, which he uses occasionally.Walter says that someone talked about him having a pendant alarm but it didn’t arrive. He had fallen 3 or 4 times in his bedroom and he didn’t know what had caused the falls. He would very much like to have a pendant alarm.A major practical issue for Walter and his adoptive family is his incontinence. Christine says that the incontinence pads cost £13 per pack and Walter sometimes goes through 2 packs per week. This is a significant drain on the family finances. They tried unsuccessfully to get them on prescription, and are now trying again. Christine explains:‘Last time, the nurse said, “Write down what he drinks, how often he drinks it, how many times he goes for a wee, see if you can measure his wee”, and I’m at it ‘You’re joking aren’t you, I’ve got four kids in the house, I can’t be running in and out of the toilet when he’s peeing’. Then when I wrote it all down she said “no, not good enough, he’s not entitled to them.” It got to the point where he was leaking on to the couch and they’re telling me he’s not good enough, you know what I mean?’Walter gave up using the telehealth equipment because the times of taking the measurements were not convenient for his family. Walter needed Christine to help him take the measurements, but because of his sleep disturbance, he did not get up until late morning – by which time Christine was up and out of the house. They only used the equipment about six or eight times in total. The researcher asks whether the telehealth equipment was useful while he was using it. He replies there were lots of health professionals coming and going. He thought the point of the telehealth equipment was to save health professionals time but, he says, it didn’t seem to.
Co-design workshops
Customisation and adaptation
‘However much training you do and however good people are at delivering telecare, unless they take into account the person’s situation and how they live in their home, it’s going to be rubbish. I mean, ranging from not noticing they’ve got a dog, a large dog, which can muck up the bed sensor something rotten, or, for instance, that they use a wok to cook with, which is not very good if you’ve got a high temperature alarm in the kitchen…But it’s really about talking to the person, spending time with them, not just once. Because the [current] idea is it’s like a prescription, isn’t it? You get this Telecare prescription and ‘there it is, bye’. But actually, it’s something you have got to work with. You’ve got to go back and go back again and make sure you review the need overall…So this always brings it home to me, you know, what you do in your case studies, what really matters…’ (Occupational Therapist)
‘If you’re working in a service, you want to know, I’m doing this, this, this and if I have done that, then it’s at the end of my duty and I can sort of pass this person on… But in reality, the situations that you face in health and social care, they’re so complex and confused that if you really wanted to address somebody’s needs, it’s like a mini project. Where do you start and where do you end?’ (Occupational Therapist)
‘Recently I did an OT assessment for a lady who was not eligible for social care. And so I went into – almost like in an advisor capacity, assessed her and everything, but it turned out what she really wanted, what was really of value to her, was completely out of the box, you know. And I kind of made loads of phone calls, I went online, to contact various people and look at websites, as we were doing this… And instead of kind of doing the standard, which I would have normally done, because it was outside of the statutory circuit I could do this. And I sort of felt, you know, this is really quite good, this is much more like a role that I believe would help people. … So it’s not all about the technology itself, it’s also about the approach.’ (Occupational Therapist)
‘I think some of the problems we’ve got is the equipment in [name of city] was bought by commissioners, non-clinicians, and had there been more engagement with the clinicians who were going to use it, who had an understanding of the patients who were going to use it, it might be slightly different than what we’ve got. They jumped in feet first. … But ultimately, the decision was made on the basis of how much money, how many units, and it was a commissioning decision, not a clinician decision.’ (Telecare Lead)
Information sharing and co-ordination
‘So if you are referring to another service for some intervention, you could have closed the case hoping the referral you’ve made is then going to do that bit of work. You might have the luxury of actually phoning or contacting that service and discussing something together, but that can be a luxury to be able to do that. Or even if you do that, that service are saying, we’ve got a two month waiting list, we can’t see this person for ages. So again, the barrier, you know, is there physically to actually work together. And then things become a bit sort of strung out, it becomes a bit like Chinese whisper, as things go through different services.’ (Occupational Therapist)
‘It might be that by knowing that, say, a district nurse is planning a review, we could slot in a couple of simple questions and save the need for another resource, or then catch up with that district nurse afterwards…Or come along, and share that information. I just don’t think we do enough of that and maybe there are some quick wins about when things are planned in.’ (Telehealth Service Manager)
‘I prefer the idea – it’s idealistic maybe, but that everything is looked at because it’s working for the person, it’s the holistic word again, but trying to get that ticking over with everyone understanding what the aims are so we’re all working towards the same thing.’ (Assistive Technology Lead for Adult Care Services, Local Authority)
Ongoing social interaction and support
‘With the carbon monoxide ones…I didn’t realise it was that, but for months I heard this beep, beep, where the hell is it coming… and it didn’t dawn on me that it was the carbon monoxide one…It wanted a battery, all it needed was a battery. But I didn’t know where the battery was going to go, I couldn’t change it....I put it on the settee behind the cushion…But it took them so long to come and change the battery for me....I rang them and told them. … And it was about two weeks before Christmas that I told them, and then one week passed and they said, “oh he’s off sick”. So it went through Christmas and then New Year and then it was January before they came.’ (Telehealth user Elsie aged 82)
‘You get, “Oh, you pull this, you pull that,” and you get muddled…We get five minutes, perhaps. They’re used to the piece of equipment, whatever you like to call it. And it is very difficult because, especially in my age group, we look such utter fools in asking for more help to understand what is going on and how it can help. Give us a five-minute talk, you’re lost…And that’s another thing, you see; if you called in perhaps the next day or a couple of days later, and had a cup of tea and that and talked it over, you’d find where the difficulties are…And that second or third visit to see would make all the difference. If you went back a week, a fortnight, later and had it out, it would be more efficient, financially as well.’ (Telecare user, Mrs K, aged 80)
‘We had a patient recently that it was just too much for her [to use telehealth] at the moment because she’s trying to get a carer for her mother, so we put her on a break for a couple of weeks. She had all the intentions to do it, but not at that time, it wasn’t, you know, it was the last thing that she needed to do.’ (Telehealth Centre Operator)
‘It’s not our job as a technology provider to create social networks for people, people can do that for themselves. We have to be aware that we don’t get in the way of those social networks…And maybe the answer isn’t to make it [the technology] as simple as possible. Maybe the answer is to make it as socially adaptive as possible. So maybe a good Telehealth system would be one that relies very strongly on [social networks].’. (Business Development Lead)
Archie: anchored, realistic, continuously co-created, human, integrated, evaluated
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Principle 1
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Design and development should be ANCHORED in a shared understanding of what matters to the patient or client
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Spend time with the individual to find out what activities and functions are personally meaningful and important to them. These are often socio-culturally framed (for example,. relating to historical accounts of their lives, family or community roles, and cultural or religious practices). ‘What matters to the person’ should be shared and understood by all involved in supporting him or her. Advocacy may be needed to represent the client and ensure their needs and goals remain central. | |
Principle 2
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The technology solution and care package should be REALISTIC about the natural history of illness and the (often progressive) impairments it may bring
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The idea that assistive technologies can cure degenerative disease or fully compensate for its effects is a modernist myth. With few exceptions, multi-morbidity steadily and inexorably compromises key aspects of functioning. Non-specific impairments (for example, chronic tiredness, loss of motivation, dulling of cognitive capacity) may interfere with a person’s ability and motivation to use a technology that has been designed to alleviate specific physical, mental or emotional impairments. Effective solutions take both the materiality and affordances (of technology) and the capability (of the user) into account. | |
Principle 3
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Solutions should be CONTINUOUSLY CO-CREATED along with users and carers, using practical reasoning and common sense
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Personalisation of solutions should be seen as a continual process that never ends, rather than as part of a standardised, one-off assessment. Formal and informal care networks require capacity to track and review the solution while in use, recognising that further customisation and innovation are likely. Creativity is needed to deal with diverse and abnormal situations, including ‘outside the box’ thinking and practical reasoning, rather than sticking rigidly to standard protocols and procedures. | |
Principle 4
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HUMAN elements (personal relationships, social networks) will make or break a telehealth or telecare solution
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Frequent inter-personal interactions with users and their carers (as informal as possible) will build their familiarity with the service and promote trust, a sense of being cared for and confidence to take the initiative if problems arise. Such interactions will also develop providers’ knowledge about key contextual factors that may have a bearing on delivery of effective and dependable support. Technology needs to be aligned with both formal and informal social support that can bridge the design-reality gap in ways that are sometimes very subtle. It is important to consider the available human resources within the intended user’s care network, and how members of this network might connect with the technology and service to support use and customisation. | |
Principle 5
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The service must be INTEGRATED by maximising mutual awareness, co-ordination and mobilisation of knowledge and expertise
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Everyone involved (both lay and professional) must be clear about the patient’s or client’s changing needs and capabilities and about the technical and social supports in place. They must also have an ongoing sense of what the other collaborators are doing to provide a context for their own activity towards the common goal of supporting the person to achieve what matters to them. To that end, it is crucial to mobilise the different knowledge and expertise within the network – both formal (shared, for example, through systematic entry and exchange of data on records) and informal (shared, for example, through storytelling, inter-disciplinary case-based discussion and informal interactions). | |
Principle 6
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EVALUATION and monitoring is essential to inform system learning
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Few telehealth and telecare programmes to date have maximised the potential to learn and improve. Technology designers and services need to monitor use and experience of technology solutions, workarounds developed for them and the repurposing of the technology and service, to inform ongoing innovation and improvements for both individual clients and the wider system. |
Discussion
Summary of key dimensions of quality
Comparison with other literature
Strengths and limitations of this study
Conclusions
Box 1: Key messages
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Telehealth and telecare technologies are not, and never will be, ‘plug and play’ or ‘one size fits all’.
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Many people who are fitted with such technologies never use them because of insufficient adaptation to the person’s physical and cognitive capabilities and/or to the personal, family, socio-cultural and organisational context(s) in which they can be made to ‘work’ (or not).
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Telehealth and telecare should be thought of as an ongoing, personalised service, supported by technology and requiring a network of lay and professional carers, not as a technology package that is installed on a one-off visit.
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We introduce the ARCHIE standards: provision of telehealth and telecare should be Anchored in a shared understanding of what matters to the user; Realistic about the natural history of illness; Co-creative, evolving and adapting solutions with users; Human, supported through interpersonal relationships and social networks; Integrated, through attention to mutual awareness and knowledge sharing; Evaluated, to drive system learning.